Category Archives: Reflections

Changes

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When I was in medical school an instructor admitted, “Half of what we teach you is wrong. The problem is, we don’t know which half.”  I could say the same about residency. Some of what I learned as an intern fell out of favor by the time I was a chief resident, such as x-ray pelvimetry to determine a woman’s likelihood of delivering vaginally, or the internist’s casual approach to glucose control in diabetic pregnant women.

The pendulum continued to swing over the next thirty some years of my career. We went from “Once a (Cesarean) section, always a section,” to “Every woman should be offered the chance to deliver vaginally after a Cesarean,” to “Let’s put a little thought into who should be doing this!”

I did a rotating internship after medical school because I had no idea which direction I should take. Obstetrics was the last thing on my mind because the physician with whom I had the most contact could be sarcastic and demeaning. That changed during two months of obstetrics in a completely different environment. I ended up taking the second-year position vacated by one of the first-year obstetrical residents who left to fulfill his three-year obligation to the U.S. Air Force. (I heard he went into radiology when he got back.)

Fast forward three decades. I was working as a locum tenens physician for the medical school I’d once attended. My old obstetrical tormentor had retired from practice but continued to be heavily involved in student and resident teaching. The years had mellowed him, or maybe it was because he didn’t have the stress and burden of a private practice.

One afternoon he asked to join me while I was doing an abdominal hysterectomy. I doubt that he remembered me from so long ago, but I was honored that he’d ask and was truly interested in what I was doing. The circle was completing; the student was now the master and the master was now “master emeritus.” Side note: I’ve never been cocky enough to consider myself a “master.”

A few months ago, I met a delightful young medical student doing her obstetrical rotation. She is intelligent, capable, ambitious and learns quickly. She began her first year as an ob/gyn resident in July, which has prompted me to reflect on what has changed since I was the youngster under the gaze of my mentors, some of whom were approaching retirement.

Ultrasound:  Ultrasound has been around since the early 1960s, but the first images looked more like abstract paintings than recognizable body parts. The ultrasound tech would swipe the transducer – a thing about the size of a restaurant salt shaker – that sent and received sound waves – back and forth across a woman’s abdomen. The results looked like this:

I couldn’t tell you what this was, and we suspected neither could most radiologists. More than once we would explore a woman’s abdomen because a radiologist swore “there is definitely an ectopic pregnancy present,” and find nothing.

Ultrasound has evolved. Machines can produce three dimensional images in real time, check on blood flow into and out of organs and measure minute structures in developing fetuses. Emergency departments now have FAST ultrasounds (Focused Assessment with Sonography in Trauma) which can rapidly detect internal bleeding or a pneumothorax (collapsed lung) at the bedside, obviating the need for a CT scan. It’s much better than the old way of diagnosing a ruptured tubal pregnancy, which was sticking an 18-gauge needle through the posterior vagina into the pelvic cavity looking for non-clotting blood.

Gonorrhea testing: Neisseria gonorrhoeae, the bacterium causing gonococcal infections, grows best within an oxygen-poor environment. We used to take a sample from a woman’s cervix, smear it across a culture plate, then stick it in a one-gallon pickle jar with a lit candle and close the lid, burning off the oxygen. By the end of the day we’d have 20 or so culture plates in the jar and the room would smell like burnt wax. Now we look for gonorrhea (and chlamydia) DNA on a cervical swab or in a urine sample.

Fetal monitors and intrauterine pressure catheters: Fetal monitors, which track a baby’s heart rate and a mother’s contractions, were introduced in the late 1960s and early 1970s.  Both were accomplished with devices placed on the mother’s abdomen, but the results often were inaccurate. The scalp electrode, created in 1972 by the venerable Dr. Ed Hon, allows us to monitor the baby’s heart directly.

The modern intrauterine pressure catheter (IUPC) measures contractions through a solid, transducer-tipped catheter threaded into the uterine cavity. The early catheters were fluid-filled tubes connected to a small strain gauge transducer which required a dome of water placed directly on the pickup before the cover was screwed on. The transducer then had to be taped to the bed rail at approximately the same height as the uterus.  Sometimes we’d use a tongue depressor and thick adhesive tape to keep it in place. Then we’d open a stopcock to “zero out” the system, close the stopcock and hoped it all worked.

Determining ruptured membranes: Back in the old days we determined if a woman had “broken her water” by inspecting the vagina with a speculum for amniotic fluid, testing any visible fluid with nitrazine paper, and then slapping some fluid on a slide, letting it dry and look through the microscope for “ferning.” If there was any question, we’d have the woman wear a pad and check for fluid an hour or so later, or, in rare cases, inject indigo carmine dye into the uterine cavity and look for blue fluid in the vagina.  When ultrasound came into widespread use, we looked at fluid levels around the baby.

Then a company created an expensive test to check for an amniotic fluid protein to determine whether membranes had ruptured. Their ad campaign preyed on all our fears by asking, “Are you really, really, absolutely, positively sure?” Hospital administrators took away our nitrazine paper and microscopes because now they had a test for which they could bill. Doctors liked it because it meant they didn’t have to stagger out of bed in the middle of the night to do an exam, or so they thought.

Then in August 2018 the FDA issued an alert reminding physicians “that the labeling for these tests specifies that they should not be used on their own to independently diagnose…ROM (rupture of membranes) in pregnant women.”

A Korean study found a positive test in a third of women in labor with intact membranes. A review of ROM testing published in The Journal of Obstetrics and Gynaecology of Canada was cautiously optimistic about protein assays although they cautioned “Further studies are needed to assess the reliability of the test according to the time from membrane rupture.” So what would make the critics happy?

We do our best, but nothing is perfect.

Hysterectomy: Vaginal hysterectomy has been compared to rebuilding an engine through the tailpipe. The Grand Old Man of vaginal hysterectomies attached to my residency program retired during my second year, so I learned to take out uteri through an abdominal incision. Not that I couldn’t do a vaginal hysterectomy, but I liked being able to see what I was doing. Few things are worse than fishing for a bleeding artery through a vagina.

Laparoscopic-assisted vaginal hysterectomy (LAVH) started to become popular in the 1990s, but the learning curve was steep. I knew physicians who spent seven hours on their first few LAVHs after going to a weekend course, which is no substitution for extensive residency training.

The alleged advantage of LAVH was being able to detach the tubes and ovaries under direct visualization, but one still had to finish the procedure vaginally. Most of the required equipment was disposable and expensive, making it 40% more expensive than a traditional vaginal hysterectomy. Some of us thought LAVH made up for a lack of skill.

Robotic surgery started becoming popular in the early 2000s, but robots were used more for marketing than for patient benefit, and they weren’t cheap. A robot cost $1-$2.5 million up front and came with a $100,000 to $170,000 annual service contract , enough to give any hospital bean counter palpitations.

But, after years of experience and refinement, doing a hysterectomy exclusively with laparoscopic equipment made total laparoscopic hysterectomy (TLH) a truly “minimally invasive surgery.” One surgical assistant told me taking the detached uterus out at the end was like uncorking a bottle. More than one study found there was no advantage to using robotics over TLH. I suspect many of those machines will be gathering dust in closets, sitting next to $100,000 carbon dioxide lasers used to treat precancerous cervical lesions before LEEP (wire-loop cautery used to whack out a chunk of cervix) became popular.

Employment: Physicians were masters of their domains for most of the twentieth century. In the early days, you graduated from medical school, did a year internship to get a license and hung out a shingle as a general practitioner.  Specialties (and specialty boards) started appearing during the 1950s, along with residency programs lasting three to seven years, and the old GP would become extinct. Physician practices were still largely independent even into the 1990s. Being employed by a hospital or, worse yet, a “goddam HMO” made you a substandard physician who couldn’t get a job anywhere else in the eyes of the Great White Fathers who still ran things.

But, as I’ve previously discussed, things have changed. By 2017 less than half of American physicians owned their own practices, especially in metropolitan areas. I live in the Chicago suburbs where a large majority of private practices have been absorbed by large medical groups and/or hospitals. New physicians expect to be employed rather than deal with the headaches inherent in independent practices: personnel, equipment, rent, taxes and liability insurance, which can run $150,000 a year for an ob/gyn. We gave up autonomy for financial security and lost both in the process.

Patient care and ownership: The generation of physicians before me cringed when administrators used terms like “customer service,” but in their hearts they knew what it meant. They took good care of their patients because those patients were their livelihood. In a group practice the patients were all OUR patients, rather than MY patients and YOUR patients.

Primary care developed “concierge care” as a backlash to corporate medicine. Concierge care promises same day or next day appointments, access to one’s physician 24/7, unhurried visits and “personalized care,” or what I used to know as “doing my damn job!”  I’ve called patients with test results, talked to them at all hours of the night and I made at least one house call to check on a patient’s Cesarean section incision that had opened up.

This “white-glove customer service” comes with annual fees ranging from $1000  to a whopping $25,000! And that is just for the privilege. Actual care still costs money. You can’t use Flexible Savings Account (FSA) or Health Savings Account (HSA) money for the fee, so this isn’t an option practical for the masses.

I’d like to think there’s a new generation of physicians willing to fix what’s broken for everyone, but I’m not holding my breath.

Atonement

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Music has always been part of my life: a blessing; a balm; sometimes a curse. A local radio station pretentiously calls Baby Boomer classics “the soundtrack of our lives.”  The pieces that have augmented my existence are less well-known: the B sides; the obscure tunes once heard only on late night radio, nurturing our ears and caressing our souls.

One of those songs is “Triad”, from Jefferson Airplane’s album Crown of Creation. It begins with two acoustic guitar chords, inevitably triggering this memory. Cue up the track here before you read further.

Summer 1975. I see my 12th floor dorm room at the University of Illinois. There is no one else around—they’ve left for the summer—and even I’m not there. The lamp on my desk provides warm but incomplete illumination. Out of the window, in the west, I see the street lights along Florida Avenue and the silhouette of the Assembly Hall, a giant, concrete flying saucer just south of Memorial Stadium.  Beyond that, in the darkness, a slowly pulsating red light on a distant transmission tower.

The second guitar comes in with a haunting melody and the scene fades to midday along a long, straight stretch of two-lane blacktop. A lonely FINA gas station sits on south side, along the edge of the cornfields. A railroad track runs parallel to the highway on the north side. The road disappears into the heat waves rising in the distance. It could be any two-lane anywhere on the prairie, but this is U.S. 36 between Decatur and Springfield. I’m going to meet my girlfriend’s parents with a mix of anticipation and fear.

You want to know how it will be
Me and her, or you and me.

Her family lives in a tired, Depression-era house with Frank Lloyd Wright moldings on the upper window panes that have been painted over several times.. Her father is an alcoholic whose mind is now that of a prize fighter punched in the head one time too many. He greets me with a grunt, trying to be cordial, but won’t look me in the eye. Her mother is a woman with black hair whom I could imagine in years past wearing one of those frilly 1950s aprons with an old, heavy stainless-steel iron with the black plastic handle and the braided cord with the round plug, smiling while ironing the laundry, a regular Suzy Homemaker. But her face is taut, having been hardened by a life she would not have deliberately chosen. It was her lot and she stayed with it. That’s what you did back then.

Her father doesn’t like me because I’m the wrong color. “Why couldn’t you have found a nice white boy?” he asked her after I left. Her mother doesn’t like me because we’re sleeping together. “I don’t like how you live,” is how she framed it. It doesn’t matter that I’m planning on going to medical school. I declare my love and devotion to her daughter but she seems to know better. Later I will contemplate awkward holiday family gatherings and realize she is right. Despite that, she sincerely thanked me when I called a few years later to let her know her daughter’s tonsillectomy went well.

Your mother’s ghost stands at your shoulder
Face like ice — a little bit colder
Saying to you — “you cannot do that, it breaks
All the rules you learned in school.”

I ask her to marry me during my first year in medical school and give her my mother’s old engagement ring, the one my father, long deceased, gave her. She picks out a wedding dress and models it for me. It truly is a fairy tale, but I am totally incapable of keeping the promise I’ve made. I’ve not yet confronted my own demons and will betray her. Through tears of anger and unspeakable pain she will rage, “You had yourself a virgin!”

Did we love each other? Or were we just looking for the love and affirmation missing from both our lives?

Four decades later, in the shadow of my eventual mortality, the guilt surprises me and I try to atone for the sins of my youth. I am not alone. Others have confessed their own transgressions to me – relationships condemned by immaturity, selfishness or fate. We all seek absolution but there are no do-overs in life, no path to penance. We can only acknowledge our trespasses against others and move on.

I’ve thought of apologizing to her, but would I be doing it for her or for me? I will never know. for some things are best left undisturbed.

Commencement

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June is the month for graduations and commencement speeches. I accomplished the former in 1979 and it’s unlikely I’ll ever be asked to do the latter. I wrote this in 1998 in response to a long-forgotten question my sister-in-law asked and revised it for this blog post.

To all graduates, family members and faculty, welcome. It’s my honor to be here today. I might not be if it was not for persistence, determination, and the fear of being stuck with loans I couldn’t repay if I was unemployed.

First, to the esteemed faculty:

When I applied to medical school, admissions committees wanted applicants who looked good on paper: science degrees, high test scores, ambitious undergraduate years, and largely male. They frequently weeded out those with the characteristics patients wanted in their own doctors, replacing them with what they were most familiar – future Great White Fathers.  If those anomalies survived medical school and residency, they were often ostracized and driven out once in practice because they refused to follow the herd and questioned what we did. The heretics among you kept you honest; you needed them to grow. And you have made progress.

Medical school classes have become more diverse. Women made up slightly more than half of applicants and new students in 2017. The FlexMed program at Mt. Sinai’s Icahn School of Medicine in New York has admitted nontraditional students for thirty years. There are fewer white and more Asian-American students admitted, but the percentage of African-American and Hispanic students remains low.  A lot of work remains.

There are many different ways to teach and to learn.  The creation of medical schools was done, in part, to standardize what was taught and to ensure some semblance of consistency in medical training.  But much has been lost confining students to classrooms and expecting them to read volumes of medical literature taken out of context.  The old guys used to say, “Look at the patient, not just at the lab tests!”  Teaching at the bedside still has a place and cannot be replaced by expensive computer-controlled models or simulations.  It can be done with integrity and respect for the patient — and for the student.

Be careful what you say, for the damage might be permanent.

I did a month rotation with a faculty urologist during my junior year of medical school. At the end he wrote “He does not have what it takes to be a physician,” on my evaluation. I should not have been surprised; his over-achieving son, a year ahead of me, had highlighted the entirety of Harrison’s Principles of Internal Medicine – a 1200-page tome – in four colors, and he had purchased his own indirect ophthalmoscope. I was stunned, humiliated, and spent the next six months wondering if he was right, if I should drop out and career for which I was better suited.

Remember the golden rule.  Do not “teach” medical students with sarcasm, derision or humiliation. Bitter, cynical students and residents become bitter and cynical physicians. We all suffer for it – patient and physician.  If you can’t say something nice, don’t say anything.  But it is not that hard to find something good in someone.

Always teach the art along with the science.  Teach students and residents to laugh and cry with their patients, to rejoice in the little accomplishments and grieve for the losses.

Above all, teach them the grave responsibility that comes with the profession. This is not shift work; a job to endure until retirement. It should still be viewed as a calling.

To the new graduates:

Even though William Hurt’s movie The Doctor is dated, all beginning medical students should be required to watch.  Your patients will be people with weaknesses and vulnerabilities hidden behind their strengths. You share those same weaknesses and vulnerabilities although you are loath to admit that to yourselves, your colleagues and your families.  Walk many miles in your patients’ shoes; you will be a better physician for it.  Accept that you are not perfect and never will be; your patients already have.

Long gone are the days when a physician hung out a shingle and practiced the way he wanted in an office he owned, before he retired after forty years. I say “he” because back then women physicians were few (and resented). Many, if not all, of you will be employed by a corporation.  Be careful and realistic.  The perceived security of a steady salary, liberal vacation and “avoiding the business hassles” comes with a hefty price tag.  When we trade autonomy for financial security, we end up with neither.  Some of my colleagues regretted selling their souls.  You will be judged on how much you cost the company, not on how compassionately you treat patients, which may adversely affect the care you provide your patients.  You will also be judged on your loyalty to those who sign your paycheck. They expect you to be a “team player,” even when the team bus is headed for a cliff. Or, as one of my former partners asked me, “Why can’t you just take the money and shut up?” Don’t leave your conscience at home.

Managed care is not intrinsically evil, but its implementation has been fouled by greed, callousness and stupidity.  It is an imperfect response to the rising cost of health care, an event which has largely been ignored by the medical profession.  My predecessors robbed the candy store and left all of us with the aftermath.

People do not trust the health care system; you can help restore that trust.  But don’t make promises you can’t keep.  Properly managed, there will be care for all.  But health care dollars are not infinite. You must choose between want and need; what is desirable and what is necessary.  As the Rolling Stones sang, “You can’t always get what you want, but if you try sometime, you just might find, you get what you need.”

Beware of the Golden Handcuffs. Avoid conspicuous consumption and remember money cannot buy happiness.  You can’t spend it if you are 6 by 6 in the dirt, and you can’t take it with you.  He who dies with the most toys still dies.  Keep in mind you will still be making more than 99% of the population.  Also remember you told the admissions committee some ridiculous story about going into medicine to help people, not to make a lot of money.  If you tell a lie long enough, it becomes the truth, so make it true.

Be kind to nurses, because they can make your life easy or a living hell. They also have your back and may one day prevent you from doing something completely stupid.  You owe them far more than those in the administrative suite who often have no idea what you really do.

Be grateful and acknowledge the other people that help you do your job: unit secretaries, housekeeping, maintenance, phlebotomists, transporters, techs. It won’t kill you to smile and say hi. Trust me, they will notice.

Find other things to do with your life.  Medicine cannot be your entire universe; you need to strike a balance in your personal life.  If not, your spouse may leave you, your kids may hate you or, worse yet, not know you.  You will be tempted to ease the pain with drugs and alcohol.  Some of you may be driven to suicide–a waste of a good doctor and the taxpayers’ money.  You won’t be much good to your patients–and yourself.

Don’t be afraid to pick up a colleague who has fallen.  Someday, the favor may be returned.  Don’t compete, keep score, or ostracize each other.  There isn’t any point.

If you find yourself wondering why you go to work in the morning, it is time to pick another profession.  If you never question why you go to work, you made the right choice.  This has been an honorable profession.  Let’s keep it that way.

Thank you and good luck.

Unrequited Love

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In the Spring a young man’s fancy lightly turns to thoughts of love.
From “Locksley Hall” by Alfred, Lord Tennyson

And when very young, to that which cannot nor should ever be.
Dr. Dave

When I was in the fourth grade I had a terrible crush on Jeannie, a blond, blue-eyed girl to whom I pledged my eternal undying love. Her twin sister, Carolyn, was a gangly brunette with glasses and braces. She was in that awkward stage through which some girls are destined to suffer and just didn’t hold the same fascination. As a callous and superficial nine-year-old kid, I saw Jeannie as beauty idealized – a living Barbie doll. Which, as most of us learn as we get older, is one of the worst criteria on which to base a relationship.

In my mind I would walk her home, hand in hand, and gently brush her lips with mine before she disappeared into her house. I would protect her from the slings and arrows of playground torment. I would be hers forever, and she, mine.

The only problem was she had no idea any of this was supposed to happen. We’d never had even a brief conversation in passing because I was too terrified to say anything. The best I could hope for was catching a glimpse of her as I rode my bike past her house, which worked out only once in two years.

Donna, the only girl I ever talked to, was more like a sister to me. We’d walk the block or so to her house and talk of simple things, much like two very good friends. Many of my adult relationships with women would follow the same two separate tracks of friend or love interest, something I’ve recognized only as I write this.

I continued to pine for Jeannie during fifth grade. She liked to play jacks with the other girls (go look it up, kids) so I bought her a set for Christmas – ten little metal spikes and a small rubber ball attached to a cheap piece of cardboard. I wrapped it and the next day unceremoniously shoved the package into her hands. “Here,” I said before turning away, avoiding the inevitable rejection.

My infatuation with Jeannie was potentially far more dangerous. I knew racial differences existed in the mid-1960s – when I was five years old a playmate’s grandmother called me a “little black liar” after a minor skirmish – but I was blissfully unaware that a poor Puerto Rican kid with kinky hair had no business being even remotely interested in a nice, middle-class white girl. I did not know that less than ten years previously a young African-American boy named Emmitt Till was savagely beaten to death in Mississippi for allegedly whistling at a white woman. I might have become St. David the Naïve, martyred for stupidity, were it not for being tragically socially inept. We moved to another school district two months into sixth grade and I never saw Jeannie again.

Make me feel the wild pulsation that I felt before the strife,
When I heard my days before me, and the tumult of my life;
Tennyson

Love may be deaf, dumb and blind, but karma has a wry sense of humor.
Dr. Dave

There was another blond girl in my new class. Anita was, as older folks would say, cute as a button: short hair; small, upturned nose; fair skin and bright, smiling eyes. Had I been paying attention I might have noticed, but avoiding further humiliation took priority.

A few days before school let out for the summer, our sixth-grade teacher, Mrs. Jackson, organized a class trip to the Chiricahua National Monument, a “Wonderland of Rocks,” about two hours from Bisbee. That morning we gathered at the playground with our sack lunches where Mrs. Jackson and a few volunteer moms herded us into their cars. I felt honored to be invited into the back seat of Mrs. Jackson’s station wagon.

We headed out Route 80 to Double Adobe Road, memorable for the frequent, gut-dropping dips in the otherwise straight and boring black top. My family had made the drive a couple of times in our navy blue ’60 Chevy Biscayne, with the wide flat fins and the trunk that could hold at least a couple of bodies. My stepfather loved to take those dips at speeds far greater than the snail’s pace I was used to in town. From there we picked up US 191 North, passing through McNeal and Elfrida, then east on Arizona SR 181 until we turned on to Bonita Canyon Road and into the park.

The road rises gently for a few miles and Bonita Creek flows past the roadside picnic area where we stopped. We ate lunch, waded through the icy water and explored some of the trails. One girl cut her foot on a sharp rock in the creek and I cleaned it with alcohol I’d brought, figuring it might come in handy.

As we were getting ready to leave, Anita came up to me and, out of the blue, said, “You know, I really like you.”  As with Jeannie, we’d never spoken a word to each other (or at least that is what I remember), but now the shoe was on the other foot and I was stunned. Any flattery I might have felt was completely overwhelmed by sheer terror and I said nothing.  It’s only now that I realize my lack of response probably hurt her feelings, and for that I’m sorry.

Truly, youth is wasted on the young.

I acquired a Bisbee High School yearbook during a trip back to Arizona in 1972. Carolyn, Donna and Anita had become lovely young women. Jeannie was the All-American girl; I would not have been surprised if she’d been elected Prom Queen. Some of the guys I’d known in grade school, on the other hand, hadn’t quite gotten their edges smoothed out. Ricky, the class clown whose twin sister once yelled, “Sit down, Junior!” in class, wore sunglasses for his yearbook picture; he might have had a future in stand-up comedy.

Knowledge comes, but wisdom lingers, and he bears a laden breast,
Full of sad experience, moving toward the stillness of his rest.
Tennyson

What he said.
Dr. Dave

More than half a century later I can only imagine what happened to them. Maybe they all got married, had kids and grandkids, and lived happily ever after. Or maybe, like most of us, the joys were enough to withstand the inevitable pain and sadness that occasionally tests even the best relationships. I’ll never know, and some things are best left undisturbed.

But wherever you are, thanks for the memories.

Spring flowers © Can Stock Photo / sborisov

 

Christmas Blues

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Some of us really hate “the most wonderful time of the year.”

It is difficult, no, it is impossible to explain our aversion to Christmas to anyone who hasn’t struggled during the holidays. We are likely to hear, “Whassamatta wit’ you? It’s Chris’mas, fer Chrissake! Stop being such a downer and get into the spirit!”

“…Crappy toys flying off the shelves
Midgets dressed up to look like elves
Spread good cheer or burn in hell…”
Denis Leary (1)

It wasn’t always this way for me. I looked forward to Christmas when I was a kid, especially the smell of a fresh-cut tree permeating the house with a scent that we enjoyed but once a year. We’d buy a tree from the stand some local fraternal organization had erected in a parking lot, then haul it back home. My parents struggled to get it into that rusting metal tree stand without losing too many needles, and then adjust the crooked trunk until the tree was as straight as possible.  We’d untangle the lights and clip them to the tree branches, sometimes swapping screw-in bulbs to balance the colors. Finally, we’d take those fragile glass ornaments from their thin cardboard boxes, shake a wire hanger loose from the pile and carefully put them on the tree, hoping they would all survive until January.

But things changed. The details aren’t important; let’s just say I cringe when I hear John Denver singing Please Daddy Don’t Get Drunk This Christmas.  It got worse after we moved from Arizona, where everyone was pretty much on the same socioeconomic plane, to the Midwest where I discovered the haves and have nots. That the sun disappeared behind endless grey skies between November and April exacerbated my own depression.

One dismal winter day in 1974 I found “The Death of Christmas: Interviews with forty-three survivors,” in the bargain bin at Follett’s Bookstore, across the street the University of Illinois Urbana-Champaign.  The proceeds from this 1971 book raised funds for the Neediest Children’s Christmas Fund in Chicago. On the cover a sad black Santa with an empty toy sack stood in the snow before three poor urban kids, a heartbreaking sight. The title page featured this illustration (2) by John Fischetti, an editorial cartoonist for the now-defunct Chicago Daily News.

A quote from one of the “survivors” summed up my feelings: “Christmas is for the rich to enjoy, the middle-class to imitate, and the poor to watch.”

A few years later I was walking down Michigan Avenue in Chicago one miserable December evening for reasons I’ve long forgotten, as I certainly didn’t have the kind of cash one needs to shop there. People hurried along the sidewalks like salmon rushing upstream to spawn. Women in furs. Businessmen in overcoats and severe looks. All the stores windows were brimming with faux Christmas cheer—the kinds of decorations no ordinary family would even think of buying—enticing the wealthy with diamonds and furs. “If you have to ask, you can’t afford it.”

A young woman sat on the cold concrete, leaning up against the marble front of a jewelry store, eerily illuminated by a light above the display window. She was rocking a young child wrapped in a thin blanket. The child’s mouth was open in a silent cry – I suspect the little girl may have suffered from cerebral palsy. A small container with a few meager coins lay at their feet. People passed them by without a glance and my heart ached at the wretched scene. I stood looking at them for a few moments, feeling helpless and confused. I don’t remember giving her any money; I think I was too shocked and ashamed. I’ve never forgotten that little scene from more than forty years ago.

The approaching holiday season triggers a predictable emotional sequence: annoyance; irritation giving way to righteous anger; resignation, relief when it’s all over followed by the post-holiday despondency. I’m annoyed when Home Depot and Costco start stocking Christmas decorations and crap in September. At least they have the decency to not play Christmas music until a week or so before Thanksgiving.

Then there’s Black Friday. The day after professing gratitude for friends and family, a roof over one’s head, and more than enough to eat, people get into fistfights over crap that will lose its appeal a few weeks into the New Year. I detest the term “Doorbusters,” which conjures a stampede of desperate peasants trying to buy their way to happiness, unaware they are being shamelessly manipulated by corporate overlords with far more money than they will ever have.

My irritation grows in direct proportion to the frequency of overly precious Christmas advertising on television and blossoms into righteous anger by late November when car commercials outnumber all others by about ten to one. Nothing captures the true meaning of Christmas like buying your spouse a luxury SUV wrapped in a gigantic red bow and telling your Yuppie kids some bullshit story about how Santa delivered it.

The post-Christmas crash follows the buildup to Christmas Day. It’s the hangover from the night before, except that night was six weeks in the making. Dried-up trees litter the curbs and dumpsters overflow with cardboard boxes and torn wrapping paper. Stores fire sale their Christmas crap up to 90% off, which gives one an idea how much it was worth in the first place. Wal-Mart starts stocking Valentine’s Day cards before New Year’s Eve. The college bowl games and the Superbowl are often anti-climactic, and I never liked basketball. Football pre-season is eight long months away.

I made a conscious effort to suppress my inner Grinch when I became a father. I didn’t want my kids to have the same dismal holiday memories I had, and I think it worked out reasonably well. (One year the oldest got a pair of pliers to pull the bug out of his pre-teen butt.) Still, the first time I read them The Polar Express I lost it at the end when Billy reflects: “At one time, most of my friends could hear the bell, but as years passed, it fell silent for all of them. Even Sarah found one Christmas that she could no longer hear its sweet sound.” (3)

My son asked, “Why are you crying, Daddy?”  You’ll figure it out in about twenty years.

I’ve made my peace with Christmas. I take delight in the little things. Classic Christmas albums by Andy Williams, Nat King Cole, Johnny Mathis and the incongruous duet with Bing Crosby and David Bowie. Christmas movies like White Christmas, Miracle on 34th Street, and Die Hard.
The guy in the neighborhood who spells BAH HUMBUG on his roof in rope lights. (I wanted to put an inflatable Grinch on the roof, but Peg promised to shoot it full of holes). The look on the Chreasters’(4) faces when they show up at 12:15 a.m. for the Christmas Eve “midnight mass” that’s been starting at 11p.m. for at least thirty years.

Christmas Day is becoming more like Thanksgiving – dinner with family and friends, wishing all peace and good will, and trying not to be a dick in the coming year. Getting stuff isn’t important; being with those you love is the best gift.

Many still find very little to celebrate around the holidays, but some churches have stepped in to fill the void.  During the 1980’s the British Columbia hospice community started “Blue Christmas” services which have since spread to churches.

“…The idea of Blue Christmas is to acknowledge the darkness, and let it be dark. That is a quietly revolutionary act in an optimism-obsessed culture that would pressure even the Little Match Girl to look on the bright side. Some churches refer to the event as the “Longest Night,” because many services take place on December 21, the winter solstice, when the sun stays hidden longer than it does on any other night of the year. The structure varies widely, but common motifs include candles, music in minor keys, periods of silence, and time to privately share specific sadnesses and fears (say, by writing them down and placing them on a “tree.”). …” (5)

If you can still hear the bell, you are indeed blessed. Please say a prayer for those for whom hope remains elusive.

  1. It’s a Merry F@#%in’ Christmas (C) 2004 Denis Leary
  2. “The Outsiders” (C) 1971, John Fischetti. Used with permission.
  3. Text from The Polar Express (C) 1985 Chris Van Allsburg.
  4. Chreasters: occasional Catholics who show up only on Christmas Eve and Easter, largely out of some subconscious obligation to the memory of long dead relatives who will chew their asses once they reach Heaven.
  5. Graham, R. “Blue Christmas Services Honor the Dark Side of the Season“. Slate, December 21, 2016. Accessed on December 7, 2017.